Healthcare Provider Details

I. General information

NPI: 1740347459
Provider Name (Legal Business Name): MARK JAMES KRIEZIS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

IV. Provider business mailing address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

V. Phone/Fax

Practice location:
  • Phone: 585-282-9906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1140606
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: